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Similaire à PMR and GCA: A GP Update - Dr Toby Helliwell
Similaire à PMR and GCA: A GP Update - Dr Toby Helliwell (20)
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PMR and GCA: A GP Update - Dr Toby Helliwell
- 1. It’s the Keele difference. Dr Toby Helliwell Delivering high quality multidisciplinary research in primary care. Polymyalgia Rheumatica (PMR) and Giant Cell Arteritis (GCA) A GP Update
- 2. Delivering high quality multidisciplinary research in primary care. Contents • Introduction • PMR: current guidance • PMR: latest research • PMR: challenges in General Practice • GCA: current guidance • GCA: latest research • GCA: challenges in General Practice • Discussion
- 3. Guess the diagnosis • 65 year old lady with aching in both shoulders • Takes 45 minutes to get going in the morning and had started getting up early to account for this • Muscle aches and pain • Impacting on activity, housework, hobbies and struggling to do her part time job
- 4. Guess the diagnosis 2 • PMHx: Hypertension (on amlodipine 5mg) • Examination – Unable to lift arms above shoulder – Bilateral upper arm tenderness • CRP 43
- 5. What happened next • Treated with 15mg prednisolone daily • One month later: – Feeling completely better – Blood tests normal • Six months later: – Still feeling completely better
- 6. GP 22 (15, M, P) “I mean, nobody ever comes in saying that they think they’ve got PMR……except those that have had it before. Or those that have got, a close relative or friend with PMR.”
- 7. A possibly more typical general practice scenario • 63 year old lady attending believing she has PMR (she read an article in the Saga magazine), several months of worsening pain and stiffness significantly affecting the shoulders but both of her hips too • Noted recent muscle aches (no better after stopping statin for 3 days) • Worse in the morning • Impacting on daily activity but has just tried to put up with it
- 8. A possibly more typical general practice scenario 2 • Known “wear and tear” in her right shoulder and “arthritis” in her right hip • PMHx: IHD (on aspirin), Pre-diabetes, Hypertension (ramipril, amlodipine), hypothyroid, overweight, on atorvastatin but wants to stop because of muscle aches • Additional information: Ex smoker, gave up after recent flu like illness in the last few weeks with residual on-going mild cough
- 9. A possibly more typical general practice scenario 3 • Examination shows reduced ROM of shoulders, chest clear, apyrexial • CXR, possible mild early COPD • CRP 17 (previous result normal) • Convinces you to start 15mg of prednisolone • After 1 week she is “cured” and so stops her medication abruptly without a relapse in symptoms.
- 10. Who gets PMR? • Average age at onset is around 70yrs • More common Northern Europe – Incidence 112/100,000 Scandinavia – Incidence 12.7/100,000 in Northern Italy • Cause unknown – Viral triggers? – Genetic predisposition? – Stress related? – Medication? • Over 80% of PMR patients are exclusively diagnosed and managed by their GP
- 11. What is PMR? • Inflammatory rheumatic disorder • Affects older patients (>50 years) • 1/1000 people aged >50 develop PMR/year • Often associated with Giant Cell Arteritis (GCA) • More common in women than men • Non-specific symptoms mimic other disorders • No diagnostic blood test • Diagnosis can be easily missed
- 13. Process of inclusion and identification
- 14. Features • Bilateral shoulder pain and stiffness • Hip girdle pain and stiffness • Early morning stiffness • Difficulties getting from chair/turning over in bed • Systemic features – Malaise – Fever – Weight loss – Fatigue • Inflammatory response
- 15. Features used for diagnosis Information removed as it contains unpublished data
- 16. Exclusion of other causes for symptoms
- 17. Differential Diagnosis • Rheumatoid athritis • Osteoarthritis • Shoulder Synovitis • Rotator cuff tendonitis • Subdeltoid bursitis • Capsulitis • Depression • Giant cell arteritis • Hypothyroidism • Polymyositis • Chronic pain syndrome • Acute or chronic infection • Endocarditis • Malignancy • Parkinson disease • RS3PE
- 18. Making a diagnosis • Challenging for GPs and specialists • Lack of a diagnostic ‘gold standard’ test • Non-specific signs and symptoms •Exclusion of other causes
- 19. Investigations
- 22. Is PMR associated with cancer? • New evidence from Keele • Data from general practice consulters • 2877 PMR patients, 9942 non-PMR patients • Higher rate of cancer diagnosis in PMR patients • Statistically significant higher rate of cancer in the first 6 months after diagnosis • No clear type of cancer associated • True association or related to misdiagnosis?
- 23. Specialists have problems too…..
- 24. Specialists have problems too….. • Testing classification criteria for research • International experts identified 128 PMR patients • 10 didn’t have PMR • 1/3 of the sample was difficult to classify • Overlap of polymyalgic symptoms in patients with a range of other disorders • Specialists find making the diagnosis challenging Dasgupta et al, 2012. Ann Rheum Dis
- 33. When to refer • Age (consider if <60 years) • Lack of shoulder involvement • Lack of inflammatory stiffness • Prominent systemic features, weight loss, night pain, neurological signs • Features of other rheumatic disease • Normal or extremely high acute-phase response • Treatment dilemmas such as: . – Incomplete, poorly sustained or non-response to corticosteroids – Inability to reduce corticosteroids – Contraindications to corticosteroid therapy – The need for prolonged corticosteroid therapy (>2 years)
- 34. Barber Annals of Rheumatic Diseases 1957 “It must be emphasised that the diagnosis, based largely on negative findings, can only be made after a lengthy period of observation”
- 35. Giant Cell Arteritis • Commonly coexists with PMR • A diagnosis not to be missed • Incidence 2/10,000 >50 years per year • Similar geography / age / gender patterns to PMR • Visual damage often irreversible – occurs in 15- 20% patients
- 37. Giant Cell Arteritis • ACR classification criteria – Age >50 years – New headache – Abnormality of temporal arteries (beaded, tender, pulseless) – ESR >50 mm/hr – Positive temporal artery biopsy – 3 of the above – sensitivity 97% Hunder et al, 1990, Arthritis & Rheumatism
- 38. Giant Cell Arteritis • Presentation often not classical • Other symptoms – Scalp tenderness – Jaw claudication – Visual disturbances – Weight loss, fever, anorexia, malaise, depression
- 41. The Pit-falls • Only 50% have typical temporal headache • 25% have no headache/head pain at all • Atypical features associated with significant delays in diagnosis • Atypical features associated with higher chance of developing irreversible blindness
- 44. Take Home Messages (PMR) • Careful follow up and or low threshold for referral in cases of atypia • Focused and vigilant follow up assessments • Appropriate initiating prednisolone dose • Review for treatment adverse effects and associations
- 45. Take Home Messages (GCA) • Consider the full range of features of GCA, not just headache • Review local pathways for further/specialist assessment • Initiate treatment if any delays in review
- 46. Discussion
- 47. Thank you Research Institute for Primary Care and Health Sciences David Wetherall Building Keele University Newcaslte-under-Lyme ST5 5BG Tel: 01782 733905 Fax: 01782 734719 www.keele.ac.uk/pchs